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Study Authors: Peter K. Lindenauer, Mihaela S. Stefan, et al.; Carolyn L. Rochester, Anne E. Holland

Target Audience and Goal Statement: Pulmonologists, hospitalists

The goal of this study was to determine the association between initiation of pulmonary rehabilitation within 90 days of hospital discharge and 1-year survival among Medicare beneficiaries with chronic obstructive pulmonary disease (COPD).

Question Addressed:

• Was initiation of pulmonary rehabilitation within 90 days of hospital discharge associated with better survival among patients with COPD?

Study Synopsis and Perspective:

Pulmonary rehabilitation involves supervised exercise training of the upper and lower extremities, education, collaborative self-management training, and psychosocial intervention for patients with respiratory diseases. Acute exacerbations of COPD — one of the most common causes of emergency hospital admission — are associated with significant reductions in physical activity, skeletal muscle function, exercise tolerance, and health-related quality of life. Pulmonary rehabilitation may counteract these negative consequences and target modifiable risk factors for hospital readmission.

A European Respiratory Society/American Thoracic Society guideline and guidance from other professional societies recommend that patients begin pulmonary rehabilitation within 3 to 4 weeks of a COPD exacerbation. According to the latest report from the Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Pulmonary Disease (GOLD), pulmonary rehabilitation is the most effective strategy to improve dyspnea and exercise capacity and tolerance, and the program is essential treatment for all patients with clinically significant COPD symptoms or with prior exacerbations.

Despite these recommendations and the fact that Medicare covers the cost of such programs, few patients with COPD participate in a pulmonary rehab program.

In a recent study in JAMA, Peter Lindenauer, MD, MSc, of the University of Massachusetts Medical School-Baystate in Springfield, and colleagues retrospectively examined the association between initiation of pulmonary rehabilitation within 90 days of hospital discharge and all-cause mortality at 1 year, based on claims data from 197,376 fee-for-service Medicare beneficiaries hospitalized for COPD in 2014, at 4,446 acute care hospitals in the U.S. Patients had a mean age of 76.9 years, and 58.6% were women.

Within 1 year of discharge, 7.3% of patients who initiated pulmonary rehab therapy within 90 days died, compared with 19.6% of patients who started pulmonary rehabilitation therapy after 90 days or did not participate in rehabilitation at all (absolute risk difference [ARD] -6.7%, 95% CI -7.9% to -5.6%; hazard ratio [HR] 0.63, 95% CI 0.57-0.69).

The researchers observed a similar trend in a propensity-matched cohort (2,710 patients in each group).

Initiation of pulmonary rehabilitation was significantly associated with lower death rates across start dates, ranging from 30 days or less (ARD -4.6%, 95% CI -5.9% to -3.2%; HR 0.74, 95% CI 0.67-0.82, P<0.001) to 61 to 90 days after hospital discharge (ARD -11.1%, 95% CI -13.2% to -8.4%; HR o.40, 95% CI 0.30-0.54, P<0.001).

After adjusting for age, comorbidities, prior home oxygen use, and frailty, an exploratory analysis evaluating the number of sessions as a continuous factor showed that every three additional sessions (a suggested weekly dose) in the first 90 days was significantly associated with lower mortality (HR 0.91, 95% CI 0.85-0.98, P=0.01).

Only 2,721 (1.5%) patients initiated pulmonary rehabilitation within 90 days of hospital discharge, and 3,161 (1.6%) initiated rehab within days 91 to 365.

Patients who started pulmonary rehabilitation within 90 days were younger, more often men, more often non-Hispanic white, and lived closer to a pulmonary rehabilitation facility.

Patients completed a median of nine sessions (interquartile range 4-14) within 3 months of leaving the hospital.

“Among the group of patients who initiated pulmonary rehabilitation within 90 days of the index hospitalization, 2,689 (98.8%) survived at least 90 days from discharge and 166 (6.2%) died within 1 year,” the researchers wrote.

Lindenauer and team acknowledged that the results may not be generalizable to younger people, since the study cohort was ≥65 years, and that there may be the potential for healthy user bias. In addition, there was a lack of randomization with respect to treatment. Patient-centered outcomes such as exercise capacity or quality of life were not available, and receipt of physical therapy or cardiac rehabilitation as an alternative to pulmonary rehabilitation were not assessed.

Source References: JAMA 2020; DOI: 10.1001/jama.2020.4437

Editorial: JAMA 2020; DOI: 10.1001/jama.2020.4436

Study Highlights and Explanation of Findings:

Initiation of pulmonary rehabilitation within 90 days of hospital discharge among COPD patients, while rare, was significantly associated with better 1-year survival compared with initiation after 90 days or no rehab at all, according to a large retrospective observational study of nearly 200,000 Medicare beneficiaries.

There was also a statistically significant association between the number of sessions completed and survival. These findings corroborate the results of many small randomized trials within routine clinical settings and therefore lend additional support to current guideline recommendations provided by professional societies in the U.S. and Europe.

However, the researchers noted that less than 2% of patients started treatment within 90 days of hospital discharge. Since noninvasive ventilation and long-term oxygen therapy are the only treatments shown to improve survival for patients requiring hospitalization for COPD, these study findings reinforced the need to develop more effective strategies for increasing participation in rehabilitation.

In an interview with MedPage Today, Carolyn Rochester, MD, of Yale University School of Medicine in New Haven, Connecticut, who co-authored an accompanying editorial, said the availability and utilization of pulmonary rehabilitation for patients with COPD varies across the country and across health systems, but remains low nationwide.

Analysis of Medicare beneficiaries data suggest that just 3-4% of patients with COPD receive pulmonary rehabilitation, she said. “The evidence for the efficacy of this therapy is now overwhelming — on par with and across more outcome areas than even bronchodilator use. It is also one of the most cost-effective COPD therapies.”

“In recent years it has also become clear that pulmonary rehabilitation benefits patients with other chronic lung disorders, including asthma and interstitial lung diseases,” she added. “This is really a very important therapy whose benefits are underrecognized.”

Rochester said lack of education and reimbursement, along with lack of access, are significant barriers to utilization of pulmonary rehabilitation in the COPD setting.

She noted that pulmonary specialists often receive little to no training in the therapy, which incorporates lung exercise training, patient education, and behavioral changes. There is also no system in place to reimburse healthcare providers for referring patients to receive it.

In the editorial, Rochester and her co-author, Anne E. Holland, PT, PhD, of Monash University in Melbourne, called for the Centers for Medicare & Medicaid Services and other insurance payers “to require referrals of suitable patients to pulmonary rehabilitation as part of national health care quality metrics,” as well as increased training for medical professionals.

Rochester said the findings should be considered a mandate for greater access and utilization of pulmonary rehabilitation in the treatment of patients with COPD: “It should drive healthcare systems to offer this, and patients to advocate more for it,” she said.

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